Microsoft word - 2010 camper application - additional forms.doc

Information Release Form
To help us determine if our camp is an appropriate setting for your child, we will need to access
confidential information from your child’s physician, social worker, caseworker, therapist,
Below you will find a statement of consent. Please sign it, and include it in the completed application packet you send back to us.
Thank your again for applying to Camp AmeriKids. If you have any questions, please do not
I, _______________________________________________, give permission for
_______________________________________________, _______________________,
Name Physician, Social Worker/Case Worker/Therapist
of ______________________________________, to provide information about
________________________________________.
Parent/Guardian Signature: _____________________________ Date: _______________
Psychosocial History Form PLEASE HAVE THIS FORM FILLED OUT BY THE CHILD’S SOCIAL WORKER, CASEMANAGER OR THERAPIST. IF UNAVAILABLE, FORM MAY BE FILLED OUT BY PARENT/GUARDIAN. CHILD’S NAME____________________________________________DATE______________ Please complete the following questions fully. The more information you are able to provide us, the more prepared we will be to deliver a safe and fun-filled summer experience to this child at camp.
In what capacity do you know the child? How well do you know the child?
What is the child’s living situation? What are the dynamics in the family?
Please tell us about the child’s progress and behavior in school:
What are the current stressors in the child’s life?
Please tell us some positive things about the child:
Please give us three words you would use to describe the child:
Do you have any concerns about how the child will behave at camp this summer?
Please provide any helpful suggestions for working with the child at camp:
Any other comments you would like to share with us:
Completed By: ____________________________________ Title: ____________________
Phone: ___________________________________Email:____________________________
Individual Orders Form

Individual orders for Name: _________________________________________

DOB: __________________Wt: ________Ht:_________

The following form must be completed and signed by the child’s physician. If the child will
be taking any prescription medication while at camp, the doctor must also complete the reverse
Individual Orders for Over the Counter/ PRN Medications
(The following medications are available in the infirmary and will be administered at the
discretion of a camp physician or nurse):
Drug Name Dosage and Indications Comments Schedule Health Care Provider (Please circle
(hives, insect bite) Continued on next page Prescription Medications
Please complete with the patient’s current regime for both scheduled and PRN medications.
Drug Name Route Indications Comments Health Care Schedule Provider

Camper’s Health Care Provider Name: Meningitis Information Sheet
I am writing to inform you about menigococcal disease (a potentially fatal bacterial infection
commonly referred to as meningitis) and a new law in New York State. On July 22, 2003, the
New York State Public Health Law (NYS PHL) was amended to include section 2167 requiring
overnight children’s camps to distribute information about meningococcal disease and
vaccination to the parents or guardians of all campers who attend camp for 7 or more nights. This
law became effective on August 15, 2003.
Camp AmeriKids is required to maintain a record of the following for each camper:
• A response to receipt of meningococcal meningitis disease and vaccine information
signed by the camper’s parent/guardian; AND
• Information on the availability and cost of meningococcal meningitis vaccine
• A record of meningococcal meningitis immunization within the past 10 years, OR
• An acknowledgement of meningoococcal meningitis disease risks and refusal of
meningococcal meningitis immunization signed by the camper’s parent/guardian.
Meningitis is rare. However, when it strikes, its flu-like symptoms make diagnosis difficult. If
not treated early, meningitis can lead to swelling of the fluid surrounding the brain and spinal
column as well as severe and permanent disabilities, such as hearing loss, brain damage,
seizures, limb amputation and even death.
Cases of meningitis among teens and young adults 15-24 years of age have more than doubled
since 1991. The disease strikes about 3,000 Americans each year and claims about 300 lives.
A vaccine is available that protects four types of the bacteria that cause meningitis in the United
States---types A, C, Y and W-135. These types account for nearly two thirds of meningitis cases
Information about the availability and cost of the vaccine can be obtained from your local
healthcare provided and by visiting the manufacturer’s website www.meningitisvaccine.com.
Camp AmeriKids is not able to provide this vaccine.
Please complete the Meningococcal Vaccination Response Form and return it to:

To learn more about meningitis and the vaccine, please feel free to contact Gaby Moss, and/or
consult your child’s physician. You can also find information about the disease at the New York
State Department of Health website: www.health.state.NY.us, and
Meningitis Vaccination Form
New York State Public Health Law requires the operator of an overnight children’s camp to
maintain a completed response form for every camper who attends camp for seven (7) or more
Check one box and sign below.
______My child has had the meningococcal meningitis immunization (Menonmune TM /
Menactra TM) within the past 10 years. Date received: ________________________
[Note: the vaccine’s protection lasts for approximately 3-5 years. Revaccination may be
_____ I have read, or have had explained to me, the information regarding meningococcal
meningitis disease. I understand the risks of not receiving the vaccine. I have decided that
my child will not obtain immunization against meningococcal meningitis disease.
Signed: _________________________________________ Date: ___________________
Camper’s Name: _________________________________ Date of Birth: ____________
Mailing Address: __________________________________________________________
HIPAA FORM
I, ________________________________________________, HEREBY AUTHORIZE AND
DIRECT the CAMP AMERIKIDS, INC. Camp Physician TO USE OR DISCLOSE MY
PROTECTED HEALTH INFORMATION (as defined herein) to the Camp AmeriKids Camp
Director as is deemed necessary by the director or the Camp Physician for the safe conduct of
In addition, I authorize the Camp Physician to request, secure and use information regarding
any prior and ongoing health condition and any prior and ongoing care and treatment from al
health care providers holding such information ( my “Protected Health Information”) including,
but not limited to: history and physical examination; admission and discharge summaries;
operative reports; progress notes and nursing notes; laboratory reports; radiology reports;
immunization records; bil ing summaries; consultation reports; pathology reports; psychological
and psychiatric assessments; and medications.
I understand that in the event I was treated for drug or alcohol abuse, psychiatric condition,
communicable diseases, including HIV/AIDS, this information wil be included as part of my
I understand that the Camp Physician may not condition treatment or eligibility to participate in
the Camp AmeriKids program on my signing this authorization.
I understand that this authorization is intended for use or disclosure of my Protected Health
Information to the extent of and as permitted by the Standards for Privacy of Individual y
Identifiable Health Information (the so-cal ed “Privacy Rule”) issued by the U.S. Department of
Health and Human Services to implement the requirement of the Health Insurance Portability
and Accounting Act of 1996 (“HIPAA”). I have been given an opportunity to inquire and request
information to my satisfaction regarding the requirements of the above law and regulations.
I understand that this authorization wil expire automatical y on the later of 90 days from the date
hereof or the end of the camp period, and I also understand that I may cancel and revoke this
authorization at any time effective upon my delivering written notice thereof to the Camp
Physician except to the extent there has already been use or disclosure in reliance on this
(Signature of Individual Camper or Legal y Guardian)
Camper’s Social Security Number: _____________________________________
Camper’s Date of Birth: ______________________________________________

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